Summary: The ‘Friendship Bench’ approach has been able to reduce the prevalence of depression in some communities in Zimbabwe, a new study reports.

Source: Grand Challenges Canada.

In Zimbabwe study, Friendship Bench therapy reduces prevalence of depression to <14%, compared to 50% in control group; First at-scale model of community mental health care in Africa has diagnosed & treated over 27,500 people for common mental disorders.

Their offices are simple wooden seats, called Friendship Benches, located in the grounds of health clinics around Harare and other major cities in Zimbabwe.

The practitioners are lay health workers known as community “Grandmothers,” trained to listen to and support patients living with anxiety, depression and other common mental disorders.

But the impact, measured in a ground-breaking study, shows that this innovative approach holds the potential to significantly improve the lives of millions of people with moderate and severe mental health problems in countries where access to treatment is limited or nonexistent.

Funded by the Government of Canada through Grand Challenges Canada, the randomised controlled trial was conducted by the University of Zimbabwe, the London School of Hygiene & Tropical Medicine and King’s College London. The study is published today in JAMA, the world’s most widely-circulated medical journal.

Six months after undergoing six weekly “problem solving therapy” sessions on the Friendship Benches, participants showed significant differences in severity of depression, anxiety, and suicidal thoughts based on locally validated questionnaires for depression and anxiety: the Shona Symptom Questionnaire (SSQ), the Patient Health Questionnaire (PHQ) and the Generalised Anxiety Disorder scale (GAD). The results were striking.

Patients with depression or anxiety who received problem-solving therapy through the Friendship Bench were more than three times less likely to have symptoms of depression after six months, compared to patients who received standard care. They were also four times less likely to have anxiety symptoms and five times less likely to have suicidal thoughts than the control group after follow-up.

50 percent of patients who received standard care still had symptoms of depression compared to 14 percent who received Friendship Bench (based on PHQ). 48 percent of patients who received standard care still had symptoms of anxiety compared to 12 percent who received Friendship Bench (based on the GAD), and 12 percent of patients who received standard care still had suicidal thoughts compared to 2 percent who received Friendship Bench (based on SSQ).

The Friendship Bench intervention was also shown to be well suited to improve health outcomes among highly vulnerable individuals. 86 percent of the study’s participants were women, over 40 percent were HIV positive, and 70 percent had experienced domestic violence or physical illness.

Lead author of the study Dr. Dixon Chibanda, a consultant psychiatrist in Harare, co-founded the Friendship Bench network in response to the appalling shortage of evidence-based treatment for people with mental disorders in Zimbabwe, a problem common throughout Africa.

While about 25 percent of the country’s primary care patients suffer from depression, anxiety and other common mental disorders, Zimbabwe (population 15 million) has only 10 psychiatrists and 15 clinical psychologists.

“Common mental disorders impose a huge burden on all countries of sub-Saharan Africa,” says Dr. Chibanda. “Developed over 20 years of community research, the Friendship Bench empowers people to achieve a greater sense of coping and control over their lives by teaching them a structured way to identify problems and find workable solutions.”

With CDN $1 million in funding from Grand Challenges Canada earlier this year, the Friendship Bench has since been scaled to 72 clinics in the cities of Harare, Gweru and Chitungwiza (total population 1.8 million). Through collaborating with a Médecins Sans Frontières psychiatric program in Zimbabwe, the Friendship Bench is working to create the largest comprehensive mental health program in sub-Saharan Africa.

To date, over 27,500 people have accessed treatment.

“In developing countries, nearly 90 percent of people with mental disorders are unable to access any treatment,” says Dr. Peter A. Singer, Chief Executive Officer of Grand Challenges Canada. “We need innovations like the Friendship Bench to flip the gap and go from 10 percent of people receiving treatment, to 90 percent of people receiving treatment.”

“In many parts of Africa, if you are poor and mentally ill, your chances of getting adequate treatment are close to zero,” says Dr. Karlee Silver, Vice President Programs at Grand Challenges Canada. “In Zimbabwe, that’s changing thanks to the Friendship Bench, the first project with the potential to make mental health care accessible to an entire African nation.”

In 2017, the team will focus on expanding the model to reach other vulnerable populations, including youth and refugees. In partnership with the Swedish NGO SolidarMed, the team intends to expand implementation of this model in Masvingo province and subsequently in the refugee centres of the eastern highlands on the border with Mozambique.

“The Friendship Bench team, working with the Zimbabwe Ministry of Health, has been able to substantially scale up services for some of the most deprived people in the community,” says Dr. Shekhar Saxena, Director of Mental Health and Substance Abuse at the World Health Organization. “By supporting the uptake of mental health innovations like the Friendship Bench, Canada is helping to turn the tide in the global mental health challenge.”

The study, published today in JAMA and supported by Grand Challenges Canada, was conducted from September 2014 to June 2015, and involved:

Identifying participants at 24 primary care clinics in Harare, divided into an intervention group (287 participants) and a control group (286). Total participants: 573.
Participants were all at least 18 years old (median age 33);

All had been assessed at 9 or higher on a 14-level “Shona Symptoms Questionnaire” (SSQ-14), an indigenous measure of common mental disorders in Zimbabwe’s Shona language . Changes in depression were measured using the PHQ-9 scale.

Excluded were patients with suicidal intent (those who were clinically depressed with suicidal thoughts and a plan for suicide), end-stage AIDS, were currently in psychiatric care, were pregnant or up to 3 months post-partum, presented with current psychosis, intoxication, and/or dementia (such patients were referred to a higher level clinic in Harare).

The control group received standard care (nurse assessment, brief support counselling, medication, referral to see a clinical psychologist and/or a psychiatrist, and Fluoxetine if warranted) plus education on common mental disorders.

Intervention group participants met on a wooden bench on the grounds of municipal clinics with trained, supervised lay health workers, popularly known as “grandmothers,” (median age 53) who provided problem solving therapy with three components — “opening up the mind, uplifting the individual, and further strengthening.”

The 45-minute sessions took place weekly for six weeks, with an optional 6-session group support program available

The “grandmothers” used mobile phones and tablets to link to specialist support. They also used a cloud-based platform that integrated the Friendship Bench project’s training, screening, patient referral and follow-up components

After three individual sessions, participants were invited to join a peer-led group called Circle Kubatana Tose, or “holding hands together,” which provided support from men and women who had benefitted from the Friendship Bench earlier. At these weekly meetings, people shared personal experiences while crocheting purses made from recycled plastic materials, the latter being an income-generating skill for participants.”

Effect of a Primary Care–Based Psychological Intervention on Symptoms of Common Mental Disorders in Zimbabwe: A Randomized Clinical Trial

Importance Depression and anxiety are common mental disorders globally but are rarely recognized or treated in low-income settings. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap.

Objective To evaluate the effectiveness of a culturally adapted psychological intervention for common mental disorders delivered by LHWs in primary care.

Design, Setting, and Participants Cluster randomized clinical trial with 6 months’ follow-up conducted from September 1, 2014, to May 25, 2015, in Harare, Zimbabwe. Twenty-four clinics were randomized 1:1 to the intervention or enhanced usual care (control). Participants were clinic attenders 18 years or older who screened positive for common mental disorders on the locally validated Shona Symptom Questionnaire (SSQ-14).

Interventions The Friendship Bench intervention comprised 6 sessions of individual problem-solving therapy delivered by trained, supervised LHWs plus an optional 6-session peer support program. The control group received standard care plus information, education, and support on common mental disorders.

Main Outcomes and Measures Primary outcome was common mental disorder measured at 6 months as a continuous variable via the SSQ-14 score, with a range of 0 (best) to 14 and a cutpoint of 9. The secondary outcome was depression symptoms measured as a binary variable via the 9-item Patient Health Questionnaire, with a range of 0 (best) to 27 and a cutpoint of 11. Outcomes were analyzed by modified intention-to-treat.

Conclusions and Relevance Among individuals screening positive for common mental disorders in Zimbabwe, LHW-administered, primary care–based problem-solving therapy with education and support compared with standard care plus education and support resulted in improved symptoms at 6 months. Scaled-up primary care integration of this intervention should be evaluated.